A 48-Year-Old With Cirrhosis and Sudden Abdominal Distension

Jennifer L. Martindale, MD; Jonathan Elmer, MD; Joshua M. Kosowsky, MD


April 05, 2023

Physical Examination and Workup

Upon arrival, his vital signs include an oral temperature of 98°F (36.7°C), a heart rate of 98 beats/min, a blood pressure of 143/60 mm Hg, a respiratory rate of 12 breaths/min, and an oxygen saturation of 98% on 2 L/min oxygen by nasal cannula. His physical examination is significant for a grossly distended abdomen, with notable periumbilical ecchymosis (positive Cullen’s sign; Figure 1), minimal abdominal tenderness (especially to deep palpation), and shifting dullness to percussion, along with marked scleral icterus and mild tremulousness.

Figure 1.

He intermittently loses orientation to time and place, with a waxing and waning pattern of attention, and appears to have difficulty responding to simple questions.

Laboratory tests performed in the ED are notable for an HCT of 24%, a platelet count of 94 × 103/μL (94 × 109/L), INR of 1.95, total serum bilirubin level of 6.9 mg/dL (117.99 µmol/L), fibrinogen level of 136 mg/dL (3.99 µmol/L), and serum potassium level of 2.9 mEq/L (2.9 mmol/L). His lactate level is 26.13 mg/dL (2.9 mmol/L). An electrocardiogram shows sinus tachycardia with U waves.

An abdominal CT scan with intravenous contrast reveals a small, nodular liver; an enlarged spleen; perisplenic collateralized vessels; and significant dense ascites (Figure 2).

Figure 2.

The fluid density is consistent with hemorrhagic ascites. The scan reveals no evidence of trauma or malignancy.

The patient is transfused with 6 units of packed red blood cells, 6 units of fresh frozen plasma (FFP), and 1 unit of cryoprecipitate. In addition, intravenous potassium, additional vitamin K, and lorazepam (for treatment of presumed alcohol withdrawal) are administered. Although his condition stabilizes during the course of his stay in the ED, his prognosis is deemed grave.


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